By Anne Huebel
“Obey implicitly the advice and directions of your medical attendant.”[I] Such was the advice of Dr. Thomas Bull for women in labor. Dr. Pye Henry Chavasse, Bull’s contemporary and rival in the advice literature industry, agreed. Doctors Bull and Chavasse wrote popular books on pregnancy, childbirth, and infant care in mid-nineteenth-century Britain. Like William Smellie a century earlier,[II] they emphasized a doctor’s right to manage a woman’s health and to expect obedience in return for their medical care. Both authors described how women should regulate their lives and bodies prior to and during pregnancy, labor, and lying-in, all of which occurred in the patient’s home. On the surface, the books encouraged women to take control of their health; however, they in fact advanced the medical management of women’s bodies.
Today in Britain, and in many other countries, pregnancy and childbirth are completely medicalized, but at the beginning of the eighteenth century, labor and birth were managed by women who were not trained medical professionals. The midwife and “gossips” (female friends and relations) delivered all babies whose births were normal and cared for the recuperating mother. A normal birth might be long and arduous, and even breech, but ended in vaginal delivery. Only in cases of obstructed births that could not be accomplished vaginally was a male medical practitioner called, usually after days of labor. His role was limited to saving the mother’s life by delivering a dead child, which he accomplished by dismemberment. The male doctor was, therefore, dreaded by the mother, who knew he would only appear when the child was already dead and her life was in extreme danger. New obstetrical instruments, such as forceps, were originally used in the seventeenth and eighteenth centuries to aid in such crises, but eventually doctors and patients realized that if the doctor was called in earlier, the instruments could be used to save some children. During the 1750s, the wealthy classes began to hire male doctors instead of midwives to deliver all babies, not just to intervene in difficult births. However, the presence of multiple women relatives and friends during the birth and post-partum period was not challenged until the nineteenth century.[III] The medicalization, or complete medical management, of birth was therefore a gradual process. Bull and Chavasse furthered the process by asserting the authority of the male medical profession over all aspects of women’s health, including normal pregnancies and deliveries and the lying-in period.
The Books: Advice for Wives and Mothers
In contrast to William Smellie, author of an obstetrics textbook for young male students, Bull and Chavasse directed their books to middle- and upper-class women. Both volumes sold well and were revised in numerous editions.[IV] Bull and Chavasse expected their readers to afford a doctor, a monthly nurse, a nursemaid, and enough other servants to free up time for expectant and new mothers to exercise, rest, and lie-in as necessary, as well as to follow the diet prescribed by the doctor. They also warned against activities believed to cause miscarriages, such as horseback riding and evening parties, indicating a well-to-do readership. Chavasse, in particular, criticized the lifestyle of the wealthy.
The present fashionable system of spending the first few months of a young married woman’s life in a round of visiting, late hours, and in close and heated rooms, calls loudly for a change. . . . How many miscarriages, premature births, and stillborn children, have resulted from such practices! . . . The first year of a married woman’s life generally determines whether she shall be healthy and strong for the remainder of her existence, or otherwise; whether she shall be the mother of fine, healthy children, or of sickly, undersized offspring,—if, indeed, she be a mother at all.[V]
Although Bull was somewhat more moderate in his tone, he gave a similar warning against dancing, riding, and “the fatiguing dissipations of fashionable life” in his first edition. In 1844, he added that honeymoon tours were too exciting and tiring for young women.[VI]
Bull and Chavasse shared a concern that young married women were not seeking out appropriate guidance about their reproductive health from the medical profession, as Bull reveals in Hints to Mothers.
I wish simply to communicate that kind of information, which every married and well-educated woman should certainly possess, and can usefully employ. To advance farther than this, to those points upon which the assistance of the medical adviser ought to be sought, would be on every account improper, and productive rather of evil than of good.[VII]
He believed women were prevented by modesty from confiding in their doctors. Nevertheless, he advised that a newly-pregnant woman should consult with a doctor quickly so that she could “seek his direction and guidance in every doubt that may arise.”[VIII] In other words, he did not provide written advice as a substitute for personal medical attention.
Dr. Chavasse likewise believed young wives avoided asking important questions.[IX] He explained that he wanted to combat the “ignorance of a Young Wife,” which was dangerous both to her own health and that of her children. However:
the diffidence of a Young Wife very much adds to the difficulty of applying a remedy.—She is usually too bashful and too sensitive to ask questions of a delicate nature; and, therefore, is compelled either to remain in ignorance, or to apply to a female friend for information, who, in the majority of cases, is as ignorant as herself in the matter.[X]
Deriding female “ignorance,” Chavasse promoted the superiority of male medical knowledge as well as weakening women’s traditional reliance on friends and relations for information about pregnancy and birth.
Thus, both doctors began their books in the belief that young married women needed advice from medical professionals to fulfill their reproductive mission. Refusal to be obedient to medical advice was likely to end in disaster.
The Successful Pregnancy and Birth
For Bull and Chavasse, medical management of childbirth should begin prior to pregnancy with the adoption of a healthy lifestyle. Once pregnancy was established, healthy habits were even more crucial, and a threatened miscarriage necessitated complete obedience to the doctor’s orders. They warned women that one miscarriage could lead to others that might even become a “habit.” Therefore, said Bull,
let the patient recollect when tempted to disobey the instructions she receives, because they may appear trifling, or a little too rigorous, that no [medical] man who enjoys her confidence would willingly lay down one rule too strict, or one injunction, the performance of which was unimportant; and remember also, that by one act of disobedience she may blast every hope of success.[XI]
As we saw earlier, Chavasse lamented that fashionable lifestyles caused miscarriages, and he criticized women for failing to prevent them by obeying their doctors’ orders.[XII]
As they described the roles of doctors and patients during labor, Bull and Chavasse revealed that women were not the passive recipients of medical advice that doctors desired. Patients tried to use the medicalization of labor to make the process faster and more comfortable. For example, Chavasse vehemently objected to demands that the doctor “take a pain” [vaginally examine the patient] frequently, which women believed would accelerate labor.[XIII] Women may have believed this because some midwives and doctors, including William Smellie, stretched the labia during labor to strengthen the pains and speed the process. Other doctors, for example Percival Willughby condemned the practice.[XIV] Unlike Smellie,[XV] both Victorian doctors emphasized the naturalness of labor and the importance of not interfering. Most labors, they agreed, were completely straightforward and did not need a doctor’s constant presence.
Their insistence on avoiding intervention did not lead to a diminishment of the doctor’s authority, however. They argued that Nature designed women to be capable of safe deliveries. The doctor merely ensured that labor was, in Bull’s words, “judiciously managed” to prevent the necessity of interference except in unusual cases.[XVI] Chavasse warned in 1864 that “Labour—and truly may it be called ‘labour’—is a natural process, and therefore, should not unnecessarily be interfered with or woe betide the unfortunate patient!” In the unfortunate circumstance that labor did not go smoothly, then “the patient must leave herself entirely in the hands of her Doctor,—to act as he thinks best.” [XVII] Bull and Chavasse were part of a movement in the medical profession to turn away from the earlier enthusiasm for using forceps and other instruments that had supported doctors’ arguments that medicalized births were safer.[XVIII] As male attendants became the norm among middle- and upper-class Britons, the trend shifted to treating pregnancy and labor as a natural, safe process and labeling too much interference as “meddlesome midwifery.”[XIX]
Another area of conflict between doctors and the demands of patients was the use of chloroform. Bull first addressed the issue in 1849 by which time he expected that most women wanted the anesthetic for ordinary labors. He was opposed to its use in normal births because he did not believe its safety had been proven. By the 1860s, Chavasse had accepted it as safe and useful in complicated births and in very hard normal labors but not in ordinary ones. Given the lack of restrictions on drugs during the period, women were able to obtain chloroform and were apparently resisting their doctors’ unwillingness to use it by administering it to themselves. Chavasse responded by stressing that it was very dangerous in the hands of anyone other than a medical man. “This advice admits of no exception.”[XX] Bull did not suggest that anyone other than doctors used the drug until the 1877 edition, which warned against self-administration and cited an 1875 case in which the unfortunate user died.[XXI]
Bull’s and Chavasse’s references to nature contain elements of Christian belief. Neither, however, made a reference to God or Providence in his descriptions of natural labor until Chavasse expanded his commentary in 1864: “Assist nature! Can anything be more absurd? As though God in his wisdom, in performing one of His greatest wonders and processes, required the assistance of man.”[XXII] Of course, this was to an extent mere rhetoric. The purpose of the doctor’s presence was to assist when births did not proceed normally, as Chavasse himself admitted.[XXIII] It might be seen as more odd that neither Bull nor Chavasse made any objections to chloroform on the basis that Christian belief condemned women to suffer in childbirth as punishment for Eve’s sin. Donald Caton and Stephanie J. Snow have argued that religious objections to chloroform have been overstated, and in the British case, at least, some doctors supported chloroform because it was morally repugnant to refuse to alleviate suffering.[XXIV] As well, Bull and Chavasse were trying to convince women that ordinary births without intervention were safest, so they were unlikely to emphasize the pain. Instead, they objected to chloroform on the basis of safety for the mother and child, and they were correct to do so as chloroform was one of the more dangerous anesthetics. Although the discovery of anesthetics had made pain less culturally acceptable, doctors knew their affects were mysterious and attended with risk.[XXV]
Patients whose demands upset Bull and Chavasse wanted to benefit from medical knowledge and employed doctors not simply to assure a healthy outcome. They were also attempting to use the medicalization of birth to make the process easier and less painful. To do so, they had to claim some control over medical decisions, such as whether to use chloroform. The doctors, however, believed their expertise and training authorized them to manage birth by withholding treatments, such as chloroform or “taking a pain,” that they deemed unnecessary, deciding when instruments and drugs were needed, and insisting that medical interventions were safe only when wielded by the doctor.
Friends and Attendants
By the mid-nineteenth century, the male control of childbirth among the middle and upper classes had so far undermined the traditionally female space of the birthing room that Bull and Chavasse both asserted medical command over which female attendants were admitted. Chavasse even went so far as to banish the patient’s mother from the room because her natural anxiety would frighten her daughter, while Bull allowed the mother to attend only if she were calm.[XXVI] Limiting the patient’s access to friends of course limited her access to traditional methods of pain and labor management. Both authors, for instance, forbade attendants from providing customary cordials, brandy, and wine thought to accelerate labor and help healing. Chavasse also prohibited caudle, the warmed, spiced ale or wine traditionally drunk by new mothers to maintain their strength.[XXVII]
Besides a friend, the other acceptable attendant was the monthly nurse, so called because she would remain to help the new mother through the lying-in period, generally a month to six weeks, at which time the patient was deemed well enough to resume her normal life (assuming an uncomplicated delivery). Bull described the ideal monthly nurse in 1844 as sober, clean, and obedient to the doctor’s orders. By 1864, Chavasse further removed control of the birthing process from the patient, who had traditionally hired the nurse, by insisting that the doctor should choose her. He also argued that monthly nurses needed to develop more professional medical skills.[XXVIII] A professionally trained nurse was taught to obey doctors, not employers (who were patients after all and subordinate to the medical professionals), while more old-fashioned nurses, chosen by the pregnant women, were attentive to what their employers wanted.
With fewer friends present and less influence over the nurse, the laboring woman in the medical model of birth was increasingly dependent on her doctor’s management and authority, and that came at the cost of the post-partum care provided by the eighteenth-century gossips. By the early twentieth century, the eighteenth-century female social sphere of birth was largely gone. In some working-class neighborhoods, women still aided each other during and after births, but most women of all classes either had to pay for nursing during lying-in or go without rest.[XXIX] Adrian Wilson sees the popularity of hospital births, beginning in the 1930s, as evidence that women were seeking the care they had lost. “Ironically . . . this moment of supreme medicalization probably restored to mothers something they had enjoyed for countless generations” because hospitals enforced a week of bed rest after the birth.[XXX]
Although their books do not contain case histories of disobedient women, as Smellie’s textbook did, Bull and Chavasse clearly feared female independence in the labor room. They included dire warnings about the results of disobedience, such as “falling down of the womb” or babies who were “unhealthy . . . dismal little old men and women.”[XXXI] The books nominally provide information to women so the women themselves could control their own health and produce robust children. However, the focus on being obedient to medical advice subordinated the female patient to the management of the male doctor. Significantly, Bull did not discuss the role of the father and Chavasse forbade his presence at the birth (without giving any reason), although it was becoming more common by the time the first editions of the books were published.[XXXII] The presence at the birth of two men with authority over the patient created the possibility of conflict between the father’s wishes and medical decision-making. Undoubtedly the doctor could not confidently demand obedience from the Victorian paterfamilias in the same way that he could from the female patient.
In the late nineteenth-century, the established medical control over birth in the middle and upper classes was further supported by increased concern about the physical health of the British Empire. Beginning in the 1870s, fears of national degeneration were created by the perception of a decline in middle-class fertility combined with the overpopulation of the “unfit” (less healthy) poor. Chavasse actually began to warn his readers about the possibility that Britain would lose control of the Empire due to a lack of healthy upper-class men in the 1860s.[XXXIII] His was a very early voice in the call for a powerful nation through healthier and more prolific motherhood, and the connection he made between the medical regulation of women’s health and national survival intensified into the early twentieth century.
Women responded to the medicalization of birth by voicing their own preferences about the birth process. Bull and Chavasse are part of a long history of the medical management of birth in which the patient as an active participant in medical choices has struggled against the medical view of the patient as a passive beneficiary of physicianly expertise. Today women in the UK are reviving elements of the female sphere of birth by hiring doulas in response to a perceived over-medicalization that creates an impersonal birth process. Predictably, the medical establishment has voiced concern about doulas interfering in medical decisions.[XXXIV] As in the Victorian period, the struggle is not between medicalized or non-medicalized childbirth, but instead it is about how medical expertise is used. Mothers want the benefit of safer births, but health outcomes are not their only concern. They also want control over how they experience one of the most pivotal events in their lives. Whether they are demanding an optional C-section or rejecting pain medications, women are defending their right to choose what happens to their bodies. Doctors want power over medical decisions because they believe their professional expertise makes their medical judgement superior to the layperson’s. Their desire for control is also understandable in today’s litigious society where they are held ultimately responsible for health outcomes. Each generation of doctors and mothers negotiates a delicate balance of power that in its happiest moments satisfies both.
Anne Huebel is an Adjunct Professor of History at Saginaw Valley State University where she teaches historical methods and European and World history. Her research interests include Victorian gender roles and the history of modern medicine.
[I] Thomas Bull, Hints to Mothers, for the Management of Health During the Period of Pregnancy, and in the Lying-In Room; with an Exposure of Popular Errors in Connexion with Those Subjects, Etc. 4th ed. (London: Longman, Brown, Green, and Longmans, 1844), 194.
[II] Marcia Nichols, “Listening Between the Lines: Patient Resistance in the Case Histories of William Smellie,” REMEDIA: The History of Medicine in Dialogue with Its Present, eds. Kate Wormersley and Lisa Haushofer, Oct. 4, 2016, https://remedianetwork.net/2016/10/04/listening-between-the-lines-patient-resistance-in-the-case-histories-of-william-smellie/.
[III] See Adrian Wilson, The Making of Man-midwifery: Childbirth in England, 1660-1770 (Cambridge, MA: Harvard University Press, 1995). Caesarian sections were almost never performed in Britain. Some continental doctors recommended them, and Catholic canon law demanded post-mortem c-sections to try to save the child. (p. 22) On the continued power of the traditional gossips, see Wilson’s discussion of Thomas Hunter, p. 176 and p. 191-192. Also see p. 204-205.
[IV]Thomas Bull, Hints to Mothers, for the Management of Health During the Period of Pregnancy, and in the Lying-In Room; with an Exposure of Popular Errors in Connexion with Those Subjects (London: Longman, Orme, Brown, Green, & Longmans, 1837). Bull’s Hints to Mothers was first published in 1837 and editions continued into the 1870s. After Bull’s death, the book was reissued and eventually revised by new editors.
Pye Henry Chavasse, Advice to a Mother on the Management of Her Offspring During the Periods of Infancy, Childhood, and Youth; Advice to Young Wives on the Management of Themselves During the Periods of Pregnancy and Lactation, 2nd ed. (London: Longman, Brown, Green, & Longmans, 1842); Advice to Wives on the Management of Themselves, During the Periods of Pregnancy, Labour and Suckling (London: Longman & Co., 1843). Chavasse’s Advice to Wives (later Advice to a Wife) began as part of the 2nd, 1842, edition of his book Advice to Mothers and was subsequently published as a separate volume in 1843. New editions were published into the twentieth century, well after the author’s death in 1879.
[V] Pye Henry Chavasse, Advice to a Wife on the Management of Her Own Health; With an Introductory Chapter Especially Addressed to a Young Wife, 4th ed. (London: John Churchill, 1861), 1-2.
[VI] Bull (1837), 103; Bull (1844), 22.
[VII] Bull (1837), 55.
[VIII] Ibid., 26.
[IX] Chavasse, Advice to Wives on the Management of Themselves, During the Periods of Pregnancy, Labour, and Suckling, from the Second London Edition (NY: D. Appleton and Co., 1844), vii.
[X] Chavasse, Advice to a Wife, 6th ed. (London: John Churchill and Sons, 1864), ix. All emphasis in quotations is in the original sources.
[XI] Bull (1837), 123-124.
[XII] Chavasse (1842), 9; (1864), 88-90.
[XIII] Bull (1837), 134-135; Chavasse (1864), 115-117.
[XIV] Wilson, The Making of Man-midwifery, 36.
[XVI] Bull (1837), 140-141.
[XVII] Chavasse (1864), 114, 119.
[XVIII] Nichols; Donald Caton, What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth From 1800 to the Present (New Haven: Yale University Press, 1999), 29; Irvine Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800-1950 (Oxford: Clarendon Press, 1992), 183-184; Wilson, The Making of Man-midwifery, 178.
[XIX] Pye Henry Chavasse, Advice to a Wife on the Management of Her Own Health; and on the Treatment of Some of the Complaints Incidental to Pregnancy, Labour, and Suckling (London: John Churchill and Sons, 1863), 109.
[XX] Bull, Hints to Mothers, 6th ed. (London: Longman, Brown, Green, & Longmans, 1849), 162-168. Not until 1877, after Bull’s death, did the new editor revise this section completely. Thomas Bull, Hints to Mothers for the Management of Health during the Period of Pregnancy and in the Lying-In Room: with an Exposure of Popular Errors in Connection with those Subjects and Hints upon Nursing. Revised by Robert W. Parker (London: Longmans, Green, and Co., 1877), 142-145. Chavasse (1864), 132-134.
[XXI] Bull (1877), 144-145.
[XXII] Chavasse (1864), 117-118.
[XXIII] Chavasse (1864), 119.
[XXIV] Caton, 29-30, 103-106; Stephanie J. Snow, Blessed Days of Anaesthesia: How Anaesthetics Changed the World (Oxford: Oxford University Press, 2008), 75-80.
[XXV] Snow, 148-164, 168-171.
[XXVI] Bull (1844), 173; Chavasse (1864), 129.
[XXVII] Bull (1844), 129-130, 133-134; Chavasse (1864), 108, 143-144; Adrian Wilson, Ritual and Conflict: The Social Relations of Childbirth in Early Modern England (London: Routledge, 2013), 158.
[XXVIII] Bull (1844), 172; Chavasse (1864), 104-105.
[XXIX] Ellen Ross, Love and Toil: Motherhood in Outcast London, 1870-1918 (Oxford: Oxford University Press, 1993), 113-118. Ross found that most mothers were able to have a short rest at least, but the Women’s Cooperative Guild letters of 1915 indicate that a significant number were unable to recuperate completely before resuming their normal hard work. Margaret Llewelyn Davies, ed., Maternity: Letters from Working Women Collected by the Women’s Cooperative Guild (NY:W. W. Norton and Co., 1978).
[XXX] Wilson, The Making of Man-midwifery, 206.
[XXXI] Bull (1837), 157; Chavasse (1863), 157.
[XXXII] Chavasse (1864), 119; John Tosh, A Man’s Place: Masculinity and the Middle-Class Home in Victorian England (New Haven, CT: Yale University Press, 2007), 81-82.
[XXXIII] See Anne Huebel, “‘More Than an Individual’: British Thoughts on Motherhood from the 1830s to World War I” (PhD diss., University of Minnesota, 2004), esp. ch. 3 and 4.
[XXXIV] See for example Hannah Fearn, “Pregnant Women Employ ‘Doulas’ for Support During Labour as NHS Cuts Hit,” The Independent 20 April 2015, http://www.independent.co.uk/life-style/health-and-families/health-news/pregnant-women-employ-doulas-for-support-during-labour-as-nhs-cuts-hit-10190834.html. A similar trend is occurring in the US. Anemona Hartocollis, “Doulas, a Growing Force in Maternity Culture, Seek Greater Acceptance,” New York Times 10 Feb. 2015, https://www.nytimes.com/2015/02/11/nyregion/doulas-the-latest-wave-in-maternity-culture-are-organizing-for-more-recognition.html; Jamie Santa Cruz, “Call the Midwife,” The Atlantic, 12 June 2015, https://www.theatlantic.com/health/archive/2015/06/midwives-are-making-a-comeback/395456/.
Front illustration: Descent of the Head
An obstetrical illustration of the normal descent of the head. Bull and Chavasse focused on ordinary, uncomplicated labors as they reassured women that they too could have a relatively easy birth if they followed their doctors’ advice. Attribution: Joseph Griffiths Swayne, Obstetric Aphorisms: For the Use of Students Commencing Midwifery Practice, from the fourth revised English edition with additions by Edward R. Hutchins (Philadelphia: Henry C. Lea, 1870), 30.